| Reg. Date | TB patient number | Name | Surname | Sex (M/F) |
Age | Phone | Known contact (yes/no) | TB risk group 1 = health care worker, 2 = miner, 3 = prison inmate, 4 = others, specify |
DR-TB risk group 1 = previous TB treatment, 2 = RR-TB contact, 3 = others, specify |
Sputum smear microscopy (two samples) | Rapid molecular test | HIV test result*** | Remarks (including TB registration number if TB is detected) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Date sputum collected | Date sputum sent to laboratory | Date smear results received | Smear microscopy received | Laboratory serial number | Date sputum collected | Date sputum sent to laboratory | Date smear results received | Smear microscopy received | Laboratory serial number | ||||||||||||